Please List Any Non-Psychiatric Medications You Are Currently Using, & Their Dosages: *

Please List Any Psychiatric Medications You Are Currently Using, & Their Dosages: *

Have You Ever Been Admitted Into A Psychiatric Hospital/Program? *

Yes No

Do You Currently Have A Mental Health Diagnosis? *

Yes No

If Yes, What Is It?

Have You Had Any Previous Therapy? *

Yes No

If So, How Much?

Any History of Physical Abuse *

Yes No

Any History of Emotional Abuse *

Yes No

Any History of Sexual Abuse *

Yes No

How Much Alcohol Do You Use? *

Do You Smoke? *

Yes No

Are You Involved In Any Legal Cases? *

Yes No

Treatment Goals

Please List Four Goals You Have For Treatment: *

Emergency Contacts

Emergency Contact Name #1 *

Emergency Contact #1 Number *

Emergency Contact #1 Relationship To Client: *

Emergency Contact #2 Name *

Emergency Contact #2 Number: *

Emergency Contact #2 Relationship To Client: *

Disclaimer

By clicking "Yes" below, I hereby give Anita Bains permission to call my emergency contact #1, and if not available #2, if she and/or I deems it appropriate when extra support is needed and/or in case of an emergency.

Yes, I Give Permission to Tracey Middleton to call my emergency contact #1, and if not available #2, if she and/or I deems it appropriate *

Today's Date *

Informed Consent

I have been informed about the field of therapeutic practice that works with one or more aspects of the human energy system to bring about body-mind relief. In addition, I have been informed about where to find scientific studies that are confirming the value of these approaches for releasing trauma and anxiety, as well as increasing relaxation, reducing pain sensation, and enhancing a sense of well-being.

I further understand that, because these methods are relatively new, the extent and breadth of their effectiveness, including benefits and risks, are not yet fully known.

Yes, I accept this term: Anita's methods are relatively new, therefore the extent and breadth of their benefits and risks, are not yet fully known. *

All of the following may arise while working with Tracey Middleton:

*Vivid or traumatic memories may fade. This could adversely impact my ability to provide legal testimony regarding a traumatic incident.

Yes I understand that vivid or traumatic memories may fade *

*Reactions may surface during a treatment session that neither Tracey Middleton nor I can fully anticipate, which may include the triggering of painful emotional and physical sensations and/or bring up additional unresolved memories.

Yes I understand and accept that unanticipated reactions may surface *

*Emotional material may continue to surface after a treatment session and give indication of other issues and events that need to be addressed.

Yes I understand and accept that Anita Bains may refer me to other practitioners *

I have considered the above information before agreeing to receive energy therapy and have obtained additional information or professional advice I consider necessary to make an informed decision. I choose to participate in energy therapy of my own free will and know I have the right to cease using these methods at any time. I agree to take fully responsibility for my self-care by sharing any discomforts or questions I have with Tracey Middleton as quickly as possible.

By clicking “Yes” below, I hereby give my informed consent to work with Anita Bains using Energy Therapy approaches that she has been trained in.

If I use tele behavioral health modalities, to help protect my confidentiality, I agree to use the Internet video service provider that is in compliance with the privacy and security regulations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA). *

I understand and agree to the possible risks of receiving therapy through electronic means even though encryption software and firewalls will be used by my therapist, which can include and not limited to:
-potential for technology failure and interruption of
services
-potential for confidentiality breaches
-Someone intentionally hacks the system and gains access
to the data
-Information stored electronically may be
subpoenaed for use during legal proceedings
-Government or law enforcement organizations may try to
gain access to information stored electronically.
I understand that I have been given a Client Identifying Number unique only to me to help secure my confidentiality and to verify that I am the person agreeing to tele behavioral health services.

By clicking “Yes” below, I hereby give my informed consent to work with Anita Bains using Energy Therapy approaches that she has been trained in.

*

Yes I give my informed consent to work with Anita Bains using Energy Therapy approaches No I need more clarifying information before I agree to work with Anita Bains and request a meeting with her to address concerns about my informed consent